We appreciate Ayers' comments calling attention to an earlier (1964) and overlooked article1 that he wrote with his colleague, Joseph Doyle. The article reviews the outcomes of 48 patients who received cardiopulmonary resuscitation on the wards and in the emergency department of a 700-bed general hospital.

Although this early study concerned in-hospital resuscitation, and the primary concern of our article2 was with out-of-hospital resuscitation, the study by Ayers and Doyles, nonetheless, provides additional confirmation for the general thesis that our article supports; namely, certain categories of patients who are receiving cardiopulmonary resuscitation are inappropriate candidates for it. We reiterate that cardiopulmonary resuscitation is not the ordinary ethical obligation of health professionals when it has a very low likelihood of success (quantitative futility) or is associated with a very poor quality of outcome (qualitative futility).2